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psnet.ahrq.gov/node/73998/psn-pdf
October 27, 2021 - The Hidden Danger of Unseen Intravenous Catheters
October 27, 2021
Vadi MG, Malkin MR. The Hidden Danger of Unseen Intravenous Catheters. PSNet [internet]. 2021.
https://psnet.ahrq.gov/web-mm/hidden-danger-unseen-intravenous-catheters
The Case
A 6-week-old infant underwent a craniotomy and excision of abnormal bra… 
                                     
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psnet.ahrq.gov/node/49778/psn-pdf
December 01, 2016 - One Dose, Two Errors
December 1, 2016
Filice GA. One Dose, Two Errors. PSNet [internet]. 2016.
https://psnet.ahrq.gov/web-mm/one-dose-two-errors
The Case
A 65-year-old woman was admitted to the intensive care unit (ICU) with severe sepsis and respiratory
failure secondary to community-acquired pneumonia. The pati… 
                                     
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psnet.ahrq.gov/node/49653/psn-pdf
May 01, 2012 - The Forgotten Line
May 1, 2012
Render ML. The Forgotten Line. PSNet [internet]. 2012.
https://psnet.ahrq.gov/web-mm/forgotten-line
The Case
An 81-year-old man with a history of coronary artery disease, hypertension, cerebrovascular accidents, and
chronic kidney disease was transferred to a referral hospital for p… 
                                     
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psnet.ahrq.gov/web-mm/misdiagnosis-pelvic-mass-versus-pregnancy
November 25, 2020 - Misdiagnosis of a Pelvic Mass versus Pregnancy 
 
 
 
 
 Citation Text: 
 Leiserowitz GS, Herding H. Misdiagnosis of a Pelvic Mass versus Pregnancy. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2020. 
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psnet.ahrq.gov/web-mm/abnormal-volunteer-results
July 18, 2016 - Abnormal Volunteer Results 
 
 
 
 
 Citation Text: 
 Fernandez C. Abnormal Volunteer Results. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2007. 
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psnet.ahrq.gov/node/49809/psn-pdf
October 01, 2017 - Hyperbilirubinemia Refractory to Phototherapy
October 1, 2017
Bhutani VK, Wong RJ. Hyperbilirubinemia Refractory to Phototherapy. PSNet [internet]. 2017.
https://psnet.ahrq.gov/web-mm/hyperbilirubinemia-refractory-phototherapy
The Case
A 1-day-old full-term infant was noted to have elevated total serum bilirubin (… 
                                     
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psnet.ahrq.gov/web-mm/dont-use-port-insert-picc
December 22, 2018 - Don't Use That Port: Insert a PICC 
 
 
 
 
 Citation Text: 
 Ilan R. Don't Use That Port: Insert a PICC. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2013. 
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psnet.ahrq.gov/web-mm/baffled-botulinum-toxin
July 17, 2024 - Baffled by Botulinum Toxin 
 
 
 
 
 Citation Text: 
 Sivaraman-Nair KP. Baffled by Botulinum Toxin. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015. 
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psnet.ahrq.gov/web-mm/incomplete-orders-hypertonic-saline-treat-hyponatremia
February 23, 2022 - Incomplete Orders for Hypertonic Saline to Treat Hyponatremia 
 
 
 
 
 Citation Text: 
 Wiegley N, Morfín JA. Incomplete Orders for Hypertonic Saline to Treat Hyponatremia. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2020. 
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psnet.ahrq.gov/primer/inpatient-transitions-care-challenges-and-safety-practices
June 15, 2024 - Inpatient Transitions of Care: Challenges and Safety Practices 
 
 
 
 
 Citation Text: 
 Satake A, McElroy V. Inpatient Transitions of Care: Challenges and Safety Practices. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2024. 
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psnet.ahrq.gov/primer/discharge-planning-and-transitions-care
June 15, 2024 - Discharge Planning and Transitions of Care 
 
 
 
 
 Citation Text: 
 Bajorek SA, McElroy V. Discharge Planning and Transitions of Care. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2020. 
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psnet.ahrq.gov/web-mm/finding-fault-default-alert
August 28, 2024 - Finding Fault With the Default Alert 
 
 
 
 
 Citation Text: 
 Baysari M. Finding Fault With the Default Alert. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2013. 
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psnet.ahrq.gov/web-mm/mid-summer-fog
September 29, 2017 - A Mid-Summer Fog 
 
 
 
 
 Citation Text: 
 Braddock CH. A Mid-Summer Fog. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2008. 
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psnet.ahrq.gov/perspective/medical-scribes-and-patient-safety
August 01, 2019 - Medical Scribes and Patient Safety 
 Deborah Woodcock, MS, MBA; Robby Bergstrom | August 1, 2019 
                       
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 View more articles from the same authors. 
 
 
 
 
 
 
 Citation Text: 
 Woodcock D, Bergstrom R. Medical Scribes and Patient Safety. PSNet [internet]. Rockv… 
                                     
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psnet.ahrq.gov/perspective/conversation-anjali-joseph-phd-edac-and-molly-m-scanlon-phd-faia-facha
June 30, 2021 - In Conversation With... Anjali Joseph, PhD, EDAC and Molly M. Scanlon, PhD, FAIA, FACHA 
 June 30, 2021 
                       
 
 
 
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 Citation Text: 
 In Conversation With.. Anjali Joseph, PhD, EDAC and Molly M. Scanlon, PhD, FAIA, FACHA. PSNet [internet]. 2021.In Conversation… 
                                     
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psnet.ahrq.gov/perspective/workarounds-and-resiliency-front-lines-health-care
August 01, 2009 - Workarounds and Resiliency on the Front Lines of Health Care 
 Anita L. Tucker, DBA, MS | August 1, 2009 
                       
 Also Read a Conversation  
 
 
 
 
 
 
 View more articles from the same authors. 
 
 
 
 
 
 
 Citation Text: 
 Tucker AL. Workarounds and Resiliency on the Front Lines of Health Care. PSN… 
                                     
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psnet.ahrq.gov/perspective/conversation-ashish-k-jha-md-mph
May 01, 2013 - In Conversation With… Ashish K. Jha, MD, MPH 
 May 1, 2013 
                       
 
 
 
 Also Read an Essay  
 
 
 
 
 
 
 
 
 
 Citation Text: 
 In Conversation With… Ashish K. Jha, MD, MPH. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2013… 
                                     
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psnet.ahrq.gov/perspective/conversation-poonam-sharma-md-mph-senior-clinical-data-analyst-atrium-health-and-rhonda
January 12, 2022 - In Conversation With... Poonam Sharma, MD, MPH, the Senior Clinical Data Analyst at Atrium Health, and Rhonda Dickman, MSN, RN, CPHQ, the Director of the Tennessee Hospital Association PSO  
 January 12, 2022 
                       
 
 
 
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 Citation Text: 
 In Conversation With.… 
                                     
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psnet.ahrq.gov/sites/default/files/2023-11/spotlight_case_the_risk_of_malpositioned.pdf
January 01, 2023 - Microsoft PowerPoint - Spotlight Case_The Risks of a Malpositioned Gastrostomy Tube_FINAL.pptx
Spotlight
The Risks of a Malpositioned Gastrostomy Tube and 
Poor Communication
Source and Credits
• This presentation is based on the November 2023 AHRQ WebM&M
Spotlight Case
o See the full article at https://psnet.ahr… 
                                     
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psnet.ahrq.gov/perspective/conversation-susan-smith-md
August 01, 2019 - In Conversation With… Susan Smith, MD 
 August 1, 2019 
                       
 
 
 
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 Citation Text: 
 In Conversation With… Susan Smith, MD. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019. 
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